The impact of the nursing workforce on patient outcomes in intensive care

Introduction: Evidence from studies conducted mainly in the US and mainland Europe suggests that characteristics of the workforce, such as nurse patient ratios and workload (measured in a number of different ways) may be linked to variations in patient outcomes across health care settings (Carmel and Rowan 2001). Few studies have tested this relationship in the UK thus questions remain about whether we are justified in extrapolating evidence from studies conducted in very different health care systems. Objectives: To investigate whether characteristics of the nursing workforce affect patient mortality UK Intensive Care Units. Data: Patient data came from the case mix programme, Intensive Care National Audit and Research Centre (ICNARC), while information about the units came from a survey of all ICUs in England (Audit Comission 1998). The merged data set contained information on 43,859 patients in 69 units across England. ICNARC also supplied a risk adjustment variable to control for patient characteristics that are often the most important determinants of survival. Methods: Multivariate multilevel logistic regression. Findings: Higher numbers of direct care nurses and lower scores on measures of workload(proportion of occupied beds at the time the patient was admitted and mean daily transfers into the unit) were associated with lower mortality rates. Furthermore, the effect of the number of direct care nurses was greatest on the life chances of the patients who were most at risk of dying. Implications: This study has wide implications for workforce policy and planning because it shows that the size of the nursing workforce is associated with mortality (West et al 2006). Few studies have demonstrated this relationship in the UK. This study has a number of strengths and weaknesses and further research is required to determine whether this relationship between the nursing workforce and patient outcomes is causal.

Caking strength of granulated clay under frozen conditions

Transport of particulate clay occurs during some extremely cold weather conditions typically in the winter in the far North area. During the transport and temporary storage time, the clay may cake inside a rail or road wagon or in a silo, and consequently be difficult to be discharged from the containers. This paper studied caking strength of a granulated clay powder with a certain water moisture content of 18% for influences of temperature, packing stress and freezing time. The temperature tested was -5 oC, -10 oC and -20 oC. Because the clay powder may be packed at different bed depth, the study was undertaken across the packing stress range at 8.3 kPa (1 m bed depth), 25.0 kPa (3 m) and 75.0 kPa (9 m). Freezing time varied between 4 hours (transport) and 18 hours (overnight). During the tests, failure of caked materials was measured using a QTS texture analyzer and the caking strength of frozen samples was calculated. Influences on freeze caking of granular clay in storage or transport are discussed briefly. Some conclusions are made at the end of the paper,including recommendations for practical methods for mitigating these problems.

Assessing the sensitivity of seagrass bed biotopes to pressures associated with marine activities.

This project was commissioned to generate an improved understanding of the sensitivities of seagrass habitats to pressures associated with human activities in the marine environment - to provide an evidence base to facilitate and support management advice for Marine Protected Areas; development of UK marine monitoring and assessment, and conservation advice to offshore marine industries. Seagrass bed habitats are identified as a Priority Marine Feature (PMF) under the Marine (Scotland) Act 2010, they are also included on the OSPAR list of threatened and declining species and habitats, and are a Habitat of Principle Importance (HPI) under the Natural Environment and Rural Communities (NERC) Act 2006, in England and Wales. The purpose of this project was to produce sensitivity assessments with supporting evidence for the HPI, OSPAR and PMF seagrass/Zostera bed habitat definitions, clearly documenting the evidence behind the assessments and any differences between assessments. Nineteen pressures, falling in five categories - biological, hydrological, physical damage, physical loss, and pollution and other chemical changes - were assessed in this report. Assessments were based on the three British seagrasses Zostera marina, Z. noltei and Ruppia maritima. Z. marina var. angustifolia was considered to be a subspecies of Z. marina but it was specified where studies had considered it as a species in its own rights. Where possible other components of the community were investigated but the basis of the assessment focused on seagrass species. To develop each sensitivity assessment, the resistance and resilience of the key elements were assessed against the pressure benchmark using the available evidence. The benchmarks were designed to provide a ‘standard’ level of pressure against which to assess sensitivity. Overall, seagrass beds were highly sensitive to a number of human activities: • penetration or disturbance of the substratum below the surface; • habitat structure changes – removal of substratum; • physical change to another sediment type; • physical loss of habitat; • siltation rate changes including and smothering; and • changes in suspended solids. High sensitivity was recorded for pressures which directly impacted the factors that limit seagrass growth and health such as light availability. Physical pressures that caused mechanical modification of the sediment, and hence damage to roots and leaves, also resulted in high sensitivity. Seagrass beds were assessed as ‘not sensitive’ to microbial pathogens or ‘removal of target species’. These assessments were based on the benchmarks used. Z. marina is known to be sensitive to Labyrinthula zosterae but this was not included in the benchmark used. Similarly, ‘removal of target species’ addresses only the biological effects of removal and not the physical effects of the process used. For example, seagrass beds are probably not sensitive to the removal of scallops found within the bed but are highly sensitive to the effects of dredging for scallops, as assessed under the pressure penetration or disturbance of the substratum below the surface‘. This is also an example of a synergistic effect Assessing the sensitivity of seagrass bed biotopes to pressures associated with marine activities between pressures. Where possible, synergistic effects were highlighted but synergistic and cumulative effects are outside the scope off this study. The report found that no distinct differences in sensitivity exist between the HPI, PMF and OSPAR definitions. Individual biotopes do however have different sensitivities to pressures. These differences were determined by the species affected, the position of the habitat on the shore and the sediment type. For instance evidence showed that beds growing in soft and muddy sand were more vulnerable to physical damage than beds on harder, more compact substratum. Temporal effects can also influence the sensitivity of seagrass beds. On a seasonal time frame, physical damage to roots and leaves occurring in the reproductive season (summer months) will have a greater impact than damage in winter. On a daily basis, the tidal regime could accentuate or attenuate the effects of pressures depending on high and low tide. A variety of factors must therefore be taken into account in order to assess the sensitivity of a particular seagrass habitat at any location. No clear difference in resilience was established across the three seagrass definitions assessed in this report. The resilience of seagrass beds and the ability to recover from human induced pressures is a combination of the environmental conditions of the site, growth rates of the seagrass, the frequency and the intensity of the disturbance. This highlights the importance of considering the species affected as well as the ecology of the seagrass bed, the environmental conditions and the types and nature of activities giving rise to the pressure and the effects of that pressure. For example, pressures that result in sediment modification (e.g. pitting or erosion), sediment change or removal, prolong recovery. Therefore, the resilience of each biotope and habitat definitions is discussed for each pressure. Using a clearly documented, evidence based approach to create sensitivity assessments allows the assessment and any subsequent decision making or management plans to be readily communicated, transparent and justifiable. The assessments can be replicated and updated where new evidence becomes available ensuring the longevity of the sensitivity assessment tool. The evidence review has reduced the uncertainty around assessments previously undertaken in the MB0102 project (Tillin et al 2010) by assigning a single sensitivity score to the pressures as opposed to a range. Finally, as seagrass habitats may also contribute to ecosystem function and the delivery of ecosystem services, understanding the sensitivity of these biotopes may also support assessment and management in regard to these. Whatever objective measures are applied to data to assess sensitivity, the final sensitivity assessment is indicative. The evidence, the benchmarks, the confidence in the assessments and the limitations of the process, require a sense-check by experienced marine ecologists before the outcome is used in management decisions.

The potential use of mapped extent and distribution of habitats as indicators of Good Environmental Status (GES)

The Healthy and Biologically Diverse Seas Evidence Group (HBDSEG) has been tasked with providing the technical advice for the implementation of the Marine Strategy Framework Directive (MSFD) with respect to descriptors linked to biodiversity. A workshop was held in London to address one of the Research and Development (R&D) proposals entitled: ‘Mapping the extent and distribution of habitats using acoustic and remote techniques, relevant to indicators for area/extent/habitat loss.’ The aim of the workshop was to identify, define and assess the feasibility of potential indicators of benthic habitat distribution and extent, and identify the R&D work which could be required to fully develop these indicators. The main points that came out of the workshop were: (i) There are many technical aspects of marine habitat mapping that still need to be resolved if cost-effective spatial indicators are to be developed. Many of the technical aspects that need addressing surround issues of consistency, confidence and repeatability. These areas should be tackled by the JNCC Habitat Mapping and Classification Working Group and the HBDSEG Seabed Mapping Working Group. (ii) There is a need for benthic ecologists (through the HBDSEG Benthic Habitats Subgroup and the JNCC Marine Indicators Group) to finalise the list of habitats for which extent and/or distribution indicators should be considered for development, building upon the recommendations from this report. When reviewing the list of indicators, benthic habitats could also be distinguished into those habitats that are defined/determined primarily by physical parameters (although including biological assemblages) (e.g. subtidal shallow sand) and those defined primarily by their biological assemblage (e.g. seagrass beds). This distinction is important as some anthropogenic pressures may influence the biological component of the ecosystem despite not having a quantifiable effect on the physical habitat distribution/extent. (iii) The scale and variety of UK benthic habitats makes any attempt to undertake comprehensive direct mapping exercises prohibitively expensive (especially where there is a need for repeat surveys for assessment). There is a clear need therefore to develop a risk-based approach that uses indirect indicators (e.g. modelling), such as habitats at risk from pressures caused by current human activities, to develop priorities for information gathering. The next steps that came out of the workshop were: (i) A combined approach should be developed by the JNCC Marine Indicators Group together with the HBDSEG Benthic Habitats Subgroup, which will compile and ultimately synthesise all the criteria used by the three different groups from the workshop. The agreed combined approach will be used to undertake a final review of the habitats considered during the workshop, and to evaluate any remaining habitats in order to produce a list of habitats for indicator development for which extent and/or distribution indicators could be appropriate. (ii) The points of advice raised at this workshop, alongside the combined approach aforementioned, and the final list of habitats for extent and/or distribution indicator development will be used to develop a prioritised list of actions to inform the next round of R&D proposals for benthic habitat indicator development in 2014. This will be done through technical discussions within JNCC and the relevant HBDSEG Subgroups. The preparation of recommendations by these groups should take into account existing work programmes, and consider the limited resources available to undertake any further R&D work.

Effect of habitat fragmentation on the macroinvertebrate infaunal communities associated with the seagrass Zostera marina

1. The effect of habitat fragmentation was investigated in two adjacent, yet separate, intertidal Zostera marina beds in the Salcombe Estuary, Devon, UK. The seagrass bed on the west bank comprised a continuous meadow of ca. 2.3 ha, whilst the bed on the east bank of the estuary was fragmented into patches of 6–9 m2.2. Three 10 cm diameter core samples for infaunal macroinvertebrates were taken from three stations within each bed. No significant difference was found in univariate community parameters between beds, or in measured seagrass parameters. However, multivariate analysis revealed a significant difference in community composition, due mainly to small changes in species abundance rather than differences in the species present.3. The species contributing most to the dissimilarity between the two communities were polychaetes generally associated with unvegetated habitats (e.g. Magelona mirabilis) and found to be more common in the fragmented bed.4. A significant difference in median grain size and sorting coefficient was recorded between the two beds, and median grain size was found to be the variable best explaining multivariate community patterns.5. The results of the study provide evidence for the effects of habitat fragmentation on the communities associated with seagrass beds, habitats which are of high conservation importance. As the infaunal community is perhaps intuitively the component least likely to be affected by fragmentation at the scale observed, the significant difference in community composition recorded has consequences for more sensitive and high-profile parts of the biota (e.g. fish), and thus for the conservation of seagrass habitats and their associated communities.

Commercial oyster stocks as a potential source of larvae in the regeneration of Ostrea edulis in Strangford Lough, Northern Ireland.

Ostrea edulis was extremely rare in the wild in Strangford Lough from the early 1900s until renewed spatfall was observed at a number of sites in the 1990s. A monitoring programme was undertaken to investigate the presence and distribution of planktonic oyster larvae at nine sites around the lough between June and September in 1997 and 1998 as a precursor to studies of spatfall patterns. Larval densities at sites in the northern basin of the lough were significantly higher than those in the southern basin where larvae were lacking or in low numbers. Densities and sizes of oyster larvae showed significant temporal variation suggesting pulsed larval release. Larval densities also showed significant spatial variation with higher densities at sites closer to commercial stocks pointing to these as the main source of oyster larvae. This hypothesis was supported during a larval flux study over a complete tidal cycle which indicated a 90% net tidal movement of O. edulis larvae from the entrance of the bay where commercial stocks were held to the main body of the lough. Thus the maintenance of dense commercial stocks of flat oysters may provide the key to the redevelopment of native oyster beds in Strangford Lough and elsewhere by providing an initial broodstock nucleus from which larvae can be exported.

Micromachined 300GHz high Q resonant slot frequency selective surface filter

The design of a low loss quasi-optical beam splitter which is required to provide efficient diplexing of the bands 316.5-325.5 GHz and 349.5-358.5 GHz is presented. To minimise the filter insertion loss, the chosen architecture is a three-layer freestanding array of dipole slot elements. Floquet modal analysis and finite element method computer models are used to establish the geometry of the periodic structure and to predict its spectral response. Two different micromachining approaches have been employed to fabricate close packed arrays of 460 mm long elements in the screens that form the basic building block of the 30mm diameter multilayer frequency selective surface. Comparisons between simulated and measured transmission coefficients for the individual dichroic surfaces are used to determine the accuracy of the computer models and to confirm the suitability of the fabrication methods.

Synchrotron X-ray diffraction study of the phase transformations in titanium alloys

High-resolution synchrotron X-ray diffraction was used to study the phase transformations in titanium alloys. Three titanium alloys were investigated: Ti-6Al-4V, Ti-6Al-2Sn-4Zr-2Mo-0.08Si and beta21s. Both room and high temperature measurements were performed. The room temperature experiments were performed to study the structure of the alloys after different heat treatments, namely as received (AR), furnace cooling (FC), water quenching (WQ) and water quenching followed by ageing. The alpha, alpha', alpha'' and beta phases were observed in different combinations depending on the heat treatment conditions and the alloy studied. A multicomponent hexagonal close packed (hcp) alpha phase, with different c and the same a lattice parameters, was detected in Ti-6Al-4V after FC. High temperature synchrotron X-ray diffraction was used for 'in situ' study of the transformations on the sample surface at elevated temperatures. The results were used to trace the kinetics of surface oxidation and the concurrent phase transformations taking place under different conditions. The influence of the temperature and oxygen content on the lattice parameters of the alpha phase was derived and new data obtained on the coefficients of thermal expansion in the different directions of the hcp alpha phase, for Ti-6Al-4V and Ti-6Al-2Sn-4Zr-2Mo-0.08Si.

Broken symmetry and pseudogaps in ropes of carbon nanotubes

Since the discovery of carbon nanotubes, it has been speculated that these materials should behave like nanoscale wires with unusual electronic properties and exceptional strength. Recently, 'ropes' of close-packed single-wall nanotubes have been synthesized in high yield. The tubes in these ropes are mainly of the (10,10) type3, which is predicted to be metallic. Experiments on individual nanotubes and ropes indicate that these systems indeed have transport properties that qualify them to be viewed as nanoscale quantum wires at low temperature. It has been expected that the close-packing of individual nanotubes into ropes does not change their electronic properties significantly. Here, however, we present first-principles calculations which show that a broken symmetry of the (10,10) tube caused by interactions between tubes in a rope induces a pseudogap of about 0.1 eV at the Fermi level. This pseudogap strongly modifies many of the fundamental electronic properties: we predict a semimetal-like temperature dependence of the electrical conductivity and a finite gap in the infrared absorption spectrum. The existence of both electron and hole charge carriers will lead to qualitatively different thermopower and Hall-effect behaviours from those expected for a normal metal.

Simulation of the surface structure of butylmethylimidazolium ionic liquids

Molecular dynamics simulations of the liquid/vacuum surfaces of the room temperature ionic liquids [bmim][PF6], [bmim][BF4] and [bmim][Cl] have been carried out at various temperatures. The surfaces are structured with a top monolayer containing oriented cations and anions. The butyl side chains tend to face the vacuum and the methyl side chains the liquid. However, as the butyl chains are not densely packed, both anions and rings are visible from the vacuum phase. The effects of temperature and the anion on the degree of cation orientation is small, but the potential drop from the vacuum to the interior of the liquid is greater for liquids with smaller anions. We compare the simulation results with a range of experimental observations and suggest that neutron reflection from samples with protiated butyl groups would be a sensitive probe of the structure.

Low-frequency electrical response to microbial induced sulfide precipitation

We investigated the sensitivity of low-frequency electrical measurements to microbe-induced metal sulfide precipitation. Three identical sand-packed monitoring columns were used; a geochemical column, an electrical column and a control column. In the first experiment, continuous upward flow of nutrients and metals in solution was established in each column. Cells of Desulfovibrio vulgaris (D. vulgaris) were injected into the center of the geochemical and electrical columns. Geochemical sampling and post-experiment destructive analysis showed that microbial induced sulfate reduction led to metal precipitation on bacteria cells, forming motile biominerals. Precipitation initially occurred in the injection zone, followed by chemotactic migration of D. vulgaris and ultimate accumulation around the nutrient source at the column base. Results from this experiment conducted with metals show (1) polarization anomalies, up to 14 mrad, develop at the bacteria injection and final accumulation areas, (2) the onset of polarization increase occurs concurrently with the onset of lactate consumption, (3) polarization profiles are similar to calculated profiles of the rate of lactate consumption, and (4) temporal changes in polarization and conduction correlate with a geometrical rearrangement of metal-coated bacterial cells. In a second experiment, the same biogeochemical conditions were established except that no metals were added to the flow solution. Polarization anomalies were absent when the experiment was replicated without metals in solution. We therefore attribute the polarization increase observed in the first experiment to a metal-fluid interfacial mechanism that develops as metal sulfides precipitate onto microbial cells and form biominerals. Temporal changes in polarization and conductivity reflect changes in (1) the amount of metal-fluid interfacial area, and (2) the amount of electronic conduction resulting from microbial growth, chemotactic movement and final coagulation. This polarization is correlated with the rate of microbial activity inferred from the lactate concentration gradient, probably via a common total metal surface area effect.

A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes

Objectives: to evaluate the effectiveness of a policy of making hip protectors available to residents of nursing homes. Design: a cluster randomised controlled trial of the policy in nursing and residential homes, with the home as the unit of randomisation. Setting: 127 nursing and residential homes in the greater Belfast area of Northern Ireland. Participants: 40 homes in the intervention group (representing 1,366 occupied beds) and 87 homes in the control group (representing 2,751 occupied beds). Interventions: a policy of making hip protectors available free of charge to residents of nursing homes and supporting the implementation process by employing a nurse facilitator to encourage staff in the homes to promote their use, over a 72-week period. Main outcome measures: the rate of hip fractures in intervention and control homes, and the level of adherence to use of hip protectors. Results: there were 85 hip fractures in the intervention homes and 163 in the control homes. The mean fracture rate per 100 residents was 6.22 in the intervention homes and 5.92 in the control homes, giving an adjusted rate ratio for the intervention group compared to the control group of 1.05 (95% CI 0.77, 1.43, P = 0.76). Initial acceptance of the hip protectors was 37.2% (508/1,366) with adherence falling to 19.9% (272/1,366) at 72 weeks. Conclusions: making hip protectors available to residents of nursing and residential homes did not reduce the rate of hip fracture.

Anti-sized reed bed system for animal wastewater treatment: a comparative study

This paper presents a comparative study on the treatment of high-strength animal wastewater in two parallel lab-scale constructed reed bed systems, progressively-sized system and anti-sized system, which have same configuration but different arrangement of bed media. The reed bed systems were operated in a tidal flow pattern to treat diluted pig slurry. Detailed analyses were carried out for the removal of some key pollutants including COD, BOD5, NH4-N, P and suspended solids. The results showed that both systems have considerable capacity for the removal of solids, organic matter and inorganic nutrients. The formation of biofilms on the surfaces of gravel media in both reed bed systems was monitored by scanning selected gravel samples using scanning electron microscopy. In general, no significant difference was detected with regard to the percentage pollutant removal in the systems. However, the anti-sized system demonstrated a clear advantage in its ability to slow down the clogging of bed media and avoid the impairment of long-term functioning and sustainability of the beds. A conceptual model was developed to predict the occurrence of the clogging. The validity of the model was tested using data from this study and from the literatures.